Develop a 3-4-page preliminary care coordination plan for an individual in your community with whom you choose to work. Identify and list available community resources for a safe and effective continuum of care.

NOTE: You are required to complete this assessment before Assessment 4.

The first step in any effective project or clinical patient encounter is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for an individual in your community as you consider the patient’s unique needs; the ethical, cultural, and physiological factors that affect care; and the critical resources available in your community that are the foundation of a safe plan for the continuum of care.

As you begin to prepare this assessment, you are encouraged to complete the Care Coordination Planning activity. Completion of this will provide useful practice, particularly for those of you who do not have care coordination experience in community settings. The information gained from completing this activity will help you succeed with the assessment. Completing formatives is also a way to demonstrate engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

• Competency 1: Adapt care based on patient-centered and person-focused factors. 

  Analyze a health concern and the associated best practices for health improvement.

• Competency 2: Collaborate with patients and family to achieve desired outcomes. 

  Establish mutually agreed-upon health goals for a care coordination plan, in collaboration with the patient.

• Competency 3: Create a satisfying patient experience. 
• Identify available community resources for a safe and effective continuum of care.
• Competency 6: Apply professional, scholarly communication strategies to lead patient-centered care. 

  Write clearly and concisely in a logically coherent and appropriate form and style.

Preparation

Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.

As you assume your expanded care coordination role, you have been tasked with addressing the specific health concerns of a particular individual within the community. You decide to prepare a preliminary care coordination plan and proceed by identifying the patient’s three priorities for health and by investigating the resources available in your community for a safe and effective continuum of care.

To prepare for this assessment, you may wish to:

• Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
• Allow plenty of time to plan your patient clinical encounter.
• Be sure that you have a patient in mind that you can work with throughout the course.

Note: Remember that you can submit all, or a portion of, your draft plan to

Smarthinking Tutoring

for feedback, before you submit the final version for this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Instructions

Note: You are required to complete this assessment before Assessment 4.

This assessment has two parts.

Part 1: Develop the Preliminary Care Coordination Plan

Complete the following:

• Identify a health concern as the focus of your care coordination plan. Possible health concerns may include, but are not limited to: 

  Stroke.
  Heart disease (high blood pressure, stroke, or heart failure).
  Home safety.
  Pulmonary disease (COPD or fibrotic lung disease).
  Orthopedic concerns (hip replacement or knee replacement).
  Cognitive impairment (Alzheimer’s disease or dementia).
  Pain management.
  Mental health.
  Trauma.

Identify available community resources for a safe and effective continuum of care.

Part 2: Secure Individual Participation in the Activity

Complete the following:

• Contact local individuals who may be open to an interview and a care coordination plan addressing their health concerns. The person you choose to work with may be a colleague, community member, friend, or family member.
• Meet with the individual to describe the care coordination plan session that you intend to provide. Collaborate with the participant in setting goals for the session, evaluating session outcomes, and suggesting possible revisions to the plan.
• Establish a tentative date and time for the care coordination plan session. Document the name of the individual and a single point of contact, either an e-mail address or a phone number.

Document Format and Length

For your care coordination plan, you may use the

Care Coordination Plan Template [DOCX]

, choose a format used in your own organization, or choose a format you are familiar with that adequately serves your needs for this assessment.

• Your preliminary plan should be 3–4 pages in length. In a separate section of the plan, identify the person you have chosen to work with, and be sure to include his or her contact information.
• Document the community resources you have identified using the Community Resources Template [DOCX].

Supporting Evidence

Cite at least two credible sources from peer-reviewed journals or professional industry publications that support your preliminary plan.

Grading Requirements

The requirements, outlined below, correspond to the grading criteria in the Preliminary Care Coordination Plan Scoring Guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed.

• Analyze your selected health concern and the associated best practices for health improvement. 

  Cite supporting evidence for best practices.
  Consider underlying assumptions and points of uncertainty in your analysis.

• Establish mutually agreed-upon health goals for the care coordination plan, in collaboration with the selected individual.

Identify available community resources for a safe and effective continuum of care.

• Write clearly and concisely in a logically coherent and appropriate form and style. 

  Write with a specific purpose with your patient in mind.
  Adhere to scholarly and disciplinary writing standards and current APA formatting requirements.

Additional Requirements

Before submitting your assessment, proofread your preliminary care coordination plan and community resources list to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your plan. Be sure to submit both documents.

CORE ELMS

Important note: The time you spend securing individual participation in this activity and the time you spend presenting your final care coordination plan to the patient in Assessment 4 must total at least three hours. Be sure to log your time in the CORE ELMS system. The CORE ELMS link is located in the courseroom navigation menu.

Care Coordination Plan Template

Name:

DOB:

Address:

Payor Source:

Secondary Source:

1. Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and
the reason for care coordination planning.)

2. Routine Health Maintenance

Physician:

Physician’s Address:

Physician’s

Phone Number:

Preferred Hospital:

General Dentist:

Dentist’s Address:

Dentist’s Phone Number:

Pharmacy:

Pharmacy’s Address:

Pharmacy’ Phone Number:

3. Specialty Care

Specialist One:

Discipline:

Physician’s Address:
Physician’s Phone Number:

Treatment Goals:

Specialist Two:

Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:

Specialist Three:

Discipline:
Physician’s Address:

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Physician’s Phone Number:
Treatment Goals:

Specialist Four:

Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:

4. Mental Health Provider

Specialist One:
Discipline:

Provider’s Address:

Provider’s Phone Number:

Treatment Goals:

5. Hospital Care (List history of hospitalizations.)

Date of Hospitalization:

Hospital Name:

Reason:

Length of Stay:

Discharged to Location:

Date of Hospitalization:
Hospital Name:
Reason:
Length of Stay:
Discharged to Location:
Date of Hospitalization:
Hospital Name:
Reason:
Length of Stay:
Discharged to Location:

6. Patient Education (List any educational program or coordination that the patient has completed.)

Name of Program:

When:

Where:

Name of Program:
When:
Where:
Name of Program:

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When:
Where:
Name of Program:
When:
Where:

7. Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term
Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.)

Name of Rehabilitation

Services:

When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:

8. Medication List (List all medications, dosage, and purpose.)

Medication:

Dosage:

Purpose:

Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
Medication:

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Dosage:
Purpose:

9. Durable Medical Equipment

Equipment Owned:

Provider:

Equipment Rented:

Provider:

Equipment Ordered:

Provider:

Equipment Needed:

Provider:

Incontinence Equipment:

Provider:

10. Home Health Care Infusion Supplies

Enteral Nutrition Provider:

Phone Number:

Parenteral Infusion Provider:

Phone Number:

11. Other Services

Social Services:

Transition Services:

Transportation Services:

12. Nursing

Skilled Nursing Visits

Name:
Services:

Indication

Treatment Goals:

Hourly Nursing Services

Name:
Services:

Indication:

Treatment Goals:

Respite Care

Name:

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Services:
Indication:
Treatment Goals:

Hospice Care

Name:
Services:
Indication:
Treatment Goals:

13. Community Services/Referrals

14. Cultural Needs

15. Signatures

RN Care Coordinator

Patient

Patient Contact Information (e-mail or phone)

1

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Community Resources Template

Mental Health Providers

Hospitals

Education Services

Rehabilitation Services

Pharmacies

DME Equipment Providers

Incontinence Service Providers

Parenteral Service Providers

Enteral Nutrition Providers

Social Services

Transition Services

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Transportation Services

Skilled Nursing Services

Hourly Nursing Services

Respite Care Services

Hospice Care Providers

Community Services
1

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